Arthroscopy & Osteotomy

Management of acetabular dysplasia and FAI, focusing on the selection between hip arthroscopy and periacetabular osteotomy (PAO) for BDDH.

Overview

Arthroscopic interventions serve as critical adjuncts or primary treatments across multiple joint pathologies, though their utility varies by anatomical site and clinical context. In the treatment of knee osteoarthritis via high tibial osteotomy, preoperative arthroscopic findings possess little to no predictive value for patient evaluation [1]. Conversely, for hip dysplasia, isolated hip arthroscopy may be a viable intervention even when not an absolute contraindication, potentially serving as a bridge to staged future periacetabular osteotomy (PAO) [11]. The combination of hip arthroscopy and PAO is safe and effective, yet clearer definitions for labral pathology and specific indications for repair or debridement remain necessary [72]. Appropriate surgical indications based on preoperative intra-articular cartilage degeneration are paramount to achieving long-term success in periacetabular osteotomy [21].

Evidence regarding the additive benefit of arthroscopy during osteotomy procedures remains mixed. There is insufficient evidence that adjunctive arthroscopy with osteotomy yields superior results compared to osteotomy alone [2]. Smaller studies incorporating second-look arthroscopy provide the most convincing evidence for the efficacy of combined arthroscopy and osteotomy procedures [4]. However, among patients requiring reoperation for intra-articular defects, the average time to reoperation was nearly 5 months shorter for patients receiving arthroscopy than for those who did not [90]. Similarly, hip arthroscopy performed after prior pelvic osteotomy improves outcomes [2], and arthroscopic revision surgery for residual femoroacetabular impingement (FAI) leads to significantly improved outcome measures with appropriate indications and expectations [3].

In other anatomical regions, arthroscopy is increasingly replacing open surgery. The number of indications for anterior ankle arthroscopy is rising, with open surgery increasingly replaced by arthroscopic techniques [91]. For tibial avulsion, arthroscopic fixation results in superior outcomes with a reduced incidence of complications compared to open techniques, although mini-open techniques demonstrate comparable efficacy in certain instances [23]. Arthroscopic femoral neck osteoplasty for FAI offers a lower major complication rate and decreased morbidity compared to open techniques, with equivalent patient outcomes at short-term and midterm follow-up [26]. More prospective studies comparing open and arthroscopic excision of ganglion cysts are needed to delineate if there is a true functional benefit [24].

Anatomy & Pathophysiology

Osseous & Pelvic Kinematics

Dynamic changes in pelvic tilt significantly influence the functional orientation of the acetabulum and must be considered [31]. In the knee, opening-wedge high tibial osteotomy changes 3D knee kinematics [36]. Three-dimensional kinematic analysis detects changes due to high tibial osteotomy (HTO) that standard radiographs do not identify, including changes in the patellofemoral (PF) joint [36]. High tibial osteotomy successfully prevents and slows the progression of knee osteoarthritis by changing the contact biomechanics [49].

Regarding acetabular dysplasia, rotational acetabular osteotomy (RAO) was more effective in relieving hip joint stress compared with shelf procedure and Chiari osteotomy [58]. The authors recommend using biomechanical analysis as an adjunct to clinical decision-making for treating dysplastic hips [30]. Conversely, despite reduction of the hip for long periods of time, acetabular remodeling did not occur in femoral varus-derotation osteotomy for spastic cerebral palsy [50].

Ligamentous & Capsular Pathology

High rates of femoroacetabular impingement (FAI) morphologic characteristics are present in patients with hip instability [54]. The position of the femoral fovea can indicate hip instability and highly correlates with lesions of the ligamentum teres [38]. The Delta Angle (DA) can be reliably measured and serves as a valuable supportive parameter in the assessment of hip microinstability [38].

Biomechanical evidence supports closure of the capsule after hip arthroscopy to reverse the significant effects of capsulotomy [32]. A substantial force is required to achieve and maintain hip distraction, with males requiring higher forces [40].

Biomechanics & Clinical Outcomes

Painless restoration of normal hip biomechanics should be the goal of clinical correction of labral dysfunction through Labral debridement, Labral repair, or Labral reconstruction [35]. Lumbopelvic stability and restoring appropriate hip biomechanics and muscle firing patterns are key to successful return to activity and sport [34]. Ongoing efforts to achieve a more precise understanding of each patient's unique pathomechanics and joint health will be mandatory to reliably alter the natural history of hip osteoarthritis [43].

In patients with risk factors such as altered biomechanics from knee procedures, hip pain or stiffness may indicate a stress fracture of the ipsilateral femoral neck, as early radiographs may be negative [37].

Classification

High Tibial Osteotomy: Arthroscopic findings prior to high tibial osteotomy have little, if any, predictive value for evaluating patients for the procedure [1].

Degenerative Medial Meniscus Posterior Root Tears: A novel arthroscopic classification based on tear gap demonstrates that higher tear types (increasing displacement of the tear gap) are associated with higher meniscal extrusion, severe chondral wear, and greater severity of arthritis [56].

Medial Meniscus Ramp Tears: An internationally developed surgically relevant classification system based on tear morphology allows for the evaluation of differing repair patterns and their effects on postoperative clinical outcomes [84].

Intra-articular Hip Pathology: Arthroscopic classification demonstrates at best moderate interrater reliability, even among high-volume hip arthroscopists [74].

Hip Arthroscopy Patient Selection: Arthroscopic surgery in patients over 50 years of age might be beneficial if classified as Tönnis grade 0 preoperatively and/or classified as Outerbridge grade II in arthroscopic findings [71].

Hip Arthroscopy Complications: A validated grading classification system for complications after hip arthroscopy yields complication rates in line with those after open surgical dislocation using the same classification system [79, 80].

Clinical Presentation

History: Preoperative arthroscopic findings have little, if any, predictive value in evaluating patients for high tibial osteotomy [1]. In femoroacetabular impingement syndrome (FAIS), untreated symptoms lasting 2 years or longer before arthroscopic management correlate with significantly worse patient-reported outcomes and higher reoperation rates at 2 years post-surgery compared to shorter symptom durations [12]. Approximately 22% of young patients undergoing hip arthroscopy for FAIS develop a clinical diagnosis of hip osteoarthritis within 2 years [59]. Conversely, arthroscopic management of FAI in adolescents yields favorable outcomes comparable to the adult population [60]. Early-term follow-up demonstrates significant improvement in outcomes measures and the 'impingement' sign following arthroscopic FAI management [13].

Inspection and Diagnostic Utility: Arthroscopy identifies previously unrecognized pathological conditions and provides significant new information about traditional problems [10]. It is necessary to substantiate the diagnosis of pigmented villonodular synovitis in the hip and assess accompanying damage [8]. Even without radiographic osteoarthritis, patients with FAI and normal radiographic joint space width have a probability of extensive articular damage [14]. Arthroscopy is an appropriate modality for addressing anterior labral tears with posterior hip subluxation or dislocation in symptomatic patients [5]. Hip arthroscopy performed after prior pelvic osteotomy improves outcomes [2].

Adjunctive Procedures and Decision Axes: There is insufficient evidence that adjunctive arthroscopy with osteotomy yields superior results compared to osteotomy alone [2]. Available information does not support one treatment modality over another regarding the interchangeability of arthroscopy and surgical dislocation for femoroacetabular impingement [18]. Judicious use of arthroscopic surgery is appropriate for managing symptomatic coexisting disease or abnormality in the presence of osteoarthritis or degeneration [39]. Surgeons should carefully assess patients with failed hip arthroscopy to identify mild to moderate dysplasia deformities not addressed by the initial arthroscopic treatment [61].

Specific Pathologies and Techniques: Arthroscopic decompression of a symptomatic anterior inferior iliac spine (AIIS) deformity is reproducible and provides excellent short-term outcomes [16]. Wrist arthroscopy requires accurate portal placement and small instrumentation to examine, probe, and treat intra-articular abnormalities [17]. The arthroscopic technique for chronic lateral epicondylitis offers advantages of earlier return to work and shorter recovery compared to open treatment, while allowing joint inspection and treatment of coexisting pathologies [19].

Safety and Complications: Knee arthroscopy is not a benign procedure [55]. Surgeons must be aware of procedure complexity, patient factors, and regional differences to reduce complications following knee arthroscopy [55]. Knee arthroscopy is effective in treating symptomatic osteoarthritis with mechanical symptoms, with 76% of patients reporting good and excellent results [62].

Investigations

Plain radiography: Thorough preoperative evaluation of radiographs is encouraged for all patients considered for hip arthroscopy, particularly in the context of iatrogenic hip instability treated with periacetabular osteotomy [66]. In patients with femoroacetabular impingement and normal radiographic joint space width, extensive articular damage may exist even without radiographic osteoarthritis [14]. Arthroscopic intervention is appropriate for addressing anterior labral tears with posterior hip subluxation or dislocation in patients with continued symptoms [5]. Arthroscopy is not recommended in cases of evolved osteoarthritis for hip femoroacetabular impingement patients [25]. Preoperative arthroscopic findings prior to high tibial osteotomy have little, if any, predictive value in evaluating patients for this procedure [1].

MRI: Routine preoperative magnetic resonance imaging for hip arthroscopy is unnecessary for patients with typical symptoms and findings, as it delays surgical intervention and increases costs without altering surgical decision-making [112]. Preoperative magnetic resonance imaging delays time to hip arthroscopy in patients aged ≤40 years with femoroacetabular impingement syndrome [98]. Gadolinium intra-articular contrast magnetic resonance imaging is not required for every patient undergoing hip arthroscopy [105]. In patients with a normal MRI without contrast and a positive response to an intra-articular injection that failed conservative management, there is a 98% chance of intra-articular hip pathology being discovered on hip arthroscopy [103]. Magnetic resonance imaging at 1 year after surgery demonstrated residual tear evidence for all patients evaluated for meniscus tear repair healing using in-office needle arthroscopy [115].

CT: Contrast magnetic resonance imaging plus computed tomography with 3-dimensional reconstruction are essential for patients requiring revision hip arthroscopy [105].

Other Considerations: Arthroscopy may be necessary to substantiate the diagnosis of pigmented villonodular synovitis in the hip and to assess and address other accompanying damage [8]. Arthroscopic excision of acetabular osteoid osteoma has been successfully performed in a 7-year-old patient, representing the youngest patient treated arthroscopically for this condition [15]. Arthroscopic decompression of a symptomatic anterior inferior iliac spine deformity is a reproducible procedure that can provide excellent outcomes at short-term follow-up [16]. Wrist arthroscopy requires accurate placement of portals and small instrumentation to examine, probe, and treat intra-articular abnormalities [17]. Available information is not sufficient to support one treatment modality over another regarding the interchangeability of hip arthroscopy and surgical dislocation for femoroacetabular impingement [18]. Arthroscopically assisted procedures may have the ability to identify concomitant injuries not initially seen on imaging or when a complete imaging evaluation is not available [104]. Post-surgical radiographic and anatomical evidence of capsular defects exists in a select group of patients following hip arthroscopy [106]. More than one half of patients undergoing revision hip arthroscopy had magnetic resonance imaging and intraoperative evidence of capsular incompetency [113]. Smaller studies that include second-look arthroscopy provide the most convincing evidence for the efficacy of combined procedures [4]. The progression of osteoarthritis after rotational acetabular osteotomy was not detected for at least twenty years in most hips with either pre-osteoarthritis or initial osteoarthritis [116].

Treatment

Non-Operative

Nonoperative treatment is the first line of treatment for most femoroacetabular impingement (FAI) patients and should not be abandoned in favor of early surgery [20]. Hip arthroscopy is an appropriate viable option for FAI only after failure to improve after a full course of physical therapy is established [20]. Conservative treatment is the initial approach for posterior ankle pathology, with arthroscopy indicated when conservative measures fail [82]. Nonoperative treatment cannot correct hallux valgus deformity but can help control symptoms [86].

Operative

Indications: The main indication for hip arthroscopy is FAI [57]. Osteotomy should be the first operation considered in a young individual with osteoarthritis of the hip, performed before there is collapse of the head or reduction of the range of flexion below 90 degrees [123]. Appropriate surgical indications based on preoperative intra-articular cartilage degeneration are paramount to achieving long-term success in PAO [21]. Arthroscopic iliopsoas lengthening is indicated for anterior iliopsoas impingement after total hip arthroplasty [22]. Arthroscopic removal of troublesome screws from slipped capital femoral epiphysis is indicated to afford minimally invasive benefits and address concomitant hip pathology [122]. Arthroscopic resection of synovial plica of the elbow is indicated if conservative treatment fails [96].

Surgical Approach / Technique: Arthroscopic management of FAI results in significant improvement in outcomes measures and the 'impingement' sign at early term follow-up [13]. Arthroscopic management of FAI in adolescents produces favorable outcomes compared with an adult control group [81]. A non-physeal-sparing arthroscopic approach for FAI in adolescents with open physes is safe and effective with no evidence of clinically relevant complication of growth arrest-related deformity or physeal instability at minimum 1 year follow-up [107]. Hip arthroscopy for FAI produces clinically meaningful outcomes in both competitive athletes and nonathletes [100]. The arthroscopic method for FAI has surgical outcomes equal to or better than open dislocation or mini-open methods, with a lower rate of major complications when performed by experienced surgeons [6]. Additional complications relating to surgical technique, such as suture anchors and femoral osteoplasty, arose as more complex FAI procedures were performed [119]. With careful selection and modern techniques, patients with dysplasia can benefit significantly and durably from arthroscopic labral repair at midterm follow-up [53]. Hip arthroscopy after prior pelvic osteotomy improves outcomes [2]. There is insufficient evidence that adjunctive arthroscopy with osteotomy yields superior results compared to osteotomy alone [2]. Arthroscopy provides a tool to treat intra-articular hip pathology secondary to dysplasia while improving bony coverage/alignment with PAO through a specialized team approach [51]. Combined one-stage treatment of non-arthritic hip dysplasia with hip arthroscopy and PAO obtained good clinical and radiological outcomes [102]. Periportal capsulotomy during hip arthroscopy results in significant clinical improvement and no postoperative instability at 1 and 2 years after surgery [121]. Spherical varus rotational osteotomy of the femur using a navigation system is an effective, less invasive alternative to trochanteric osteotomy (TRO) for patients with extensive femoral head necrosis who would have otherwise required rotational osteotomy [47]. The modified Salter osteotomy is technically more difficult than the regular Salter osteotomy and is not intended to routinely replace it [29].

Implant Selection: Osteotomy fixation with 3 proximal and 3 distal screws in opening-wedge high tibial osteotomy is associated with osteotomy healing [118]. Arthroscopic stabilization with resorbable devices for glenohumeral stabilization is a highly reliable procedure, though not devoid of complications such as anterior glenoid rim fracture [109]. The described technique for arthroscopic locking plate removal after proximal humeral fractures is recommended for all surgeons familiar with arthroscopic surgery [41]. Surgeons should view cementless stem removal systems as valuable adjuncts rather than replacements for traditional osteotomies, and must remain vigilant in case selection and intraoperative execution [89].

Alignment / Balancing Strategy: The role of osteotomy in contemporary surgical treatment of hip osteoarthritis may be better defined by understanding its mechanical and cellular basis [7]. Modification of techniques such as pelvic osteotomy and introduction of intracapsular procedures have provided options for surgical treatment of sequelae of childhood conditions and FAI [9]. Arthroscopic findings prior to high tibial osteotomy have little, if any, predictive value in evaluating patients for the procedure [1].

Pain Management: Intraarticular use of ropivacaine provides an alternative and effective solution in pain control after knee arthroscopy [64]. Pericapsular injection is a safe intervention that allows for efficient postoperative analgesia for patients undergoing hip arthroscopy [70]. A preoperative femoral nerve block is a relatively safe procedure that may decrease the requirement for intraoperative morphine while providing effective postoperative pain control in patients undergoing hip arthroscopic surgery [88]. Intraarticular injections of local anaesthetics provide an alternative and effective solution in pain control after knee arthroscopy [64].

Adjuncts: Risk factors for heat-related complications from radiofrequency and electrocautery devices in arthroscopic surgery include leakage of arthroscopy fluid, use of a thermal device, intra-articular anesthetics/pain pumps, and performing specific surgical procedures [93]. Relief of pain is the most gratifying aspect of arthroscopic surgery for pigmented villonodular synovitis from the patients' point of view [111].

Other Considerations: Hip dysplasia may not be an absolute contraindication for isolated hip arthroscopy and may serve as a viable intervention with consideration of staged future periacetabular osteotomy (PAO) [11]. Suggested guidelines for the practice of arthroscopic surgery emphasize the need for appropriate training, privileges, and performance review by the Arthroscopy Association of North America [67]. Suggested guidelines for the practice of arthroscopic surgery emphasize the need for appropriate training, privileges, and performance review by the Arthroscopy Association of North America [68]. Suggested guidelines for the practice of arthroscopic surgery emphasize the need for appropriate training, privileges, and performance review by the Arthroscopy Association of North America [69]. There is no single 'right way' to be an expert arthroscopist, as varied approaches and techniques among luminaries all yield superb patient outcomes [45].

Complications

Thromboembolism: The incidence of symptomatic postoperative venous thromboembolism (VTE) following hip arthroscopy is low [108], with short-term complication rates, including DVT and PE, remaining low [99]. A 2.0% VTE event rate suggests prophylaxis may not be necessary in low-risk patients, although true rates may be under-reported [114]. Risk factors for postoperative VTE include obesity, smoking, age >45 years, oral contraceptive use, and malignancy [133], [134]. Obese patients face significantly increased risks of DVTs and worsened hip pain [136]. Single-dose intravenous tranexamic acid does not increase the VTE or overall complication rate [137]. Thromboembolic complications do occur after elective hip arthroscopy [120], and distinct differences in thrombosis risk exist per person after knee arthroscopy [110]. Patients undergoing closed-wedge high tibial osteotomy are also at risk of postoperative VTE [140].

Infection (PJI): The overall rate of surgical site infections is low following hip arthroscopy [155]. Periprosthetic joint infection incidence rates range from 0.4% to 2% after primary total knee replacement [135].

General Complication Rates: In an analysis of 2,640 arthroscopic procedures, the complication rate was 8.2% [127]. The rate of major complications after hip arthroscopy was 0.58% [154]. Primary hip arthroscopy shows low 90-day adverse events at 1.28% and a 5-year secondary surgery rate of 4.9% [150]. The reoperation rate after revision hip arthroscopy is 5% within 2 years, including further arthroscopy or conversion to hip arthroplasty [149]. Arthroscopy remains central to orthopedic research due to low complication risk and morbidity [161]. However, harms reporting is inadequate in most systematic reviews concerning hip arthroscopy [152]. Surgeons must learn from complications through careful review of etiology and prevention [139].

Other Considerations: Arthroscopic hip revision for residual FAI leads to significantly improved outcomes with appropriate indications [3]. The arthroscopic method for FAI has outcomes equal to or better than open/mini-open methods, with lower major complication rates when performed by experienced surgeons [6]. Arthroscopic femoral neck osteoplasty for FAI has lower major complication rates, decreased morbidity, and equivalent short/midterm outcomes compared to open techniques [26]. Repeat revision hip arthroscopy results in clinically significant improvement but outcomes similar to first-time revision and inferior to primary surgeries [130]. Revision hip arthroscopic surgery improves outcomes in the first 3 years, with significant improvement only in the first 2 years [156]. Arthroscopic iliopsoas lengthening for anterior impingement post-THA had minimal complications, provided pain relief in 80% of patients, and avoided major revision in 100% of cases [22]. Arthroscopy for isolated tibial avulsion resulted in superior outcomes and reduced complications compared to open fixation, though mini-open demonstrated comparable efficacy [23]. Arthroscopic labral reconstruction reported functional improvements and low complication/revision/arthritis progression rates, though graft types and concomitant procedures confound results [141]. Segmental and circumferential acetabular labral reconstruction have comparable outcomes with no clinical superiority for either technique [148]. Patients with borderline dysplastic hips achieve equivalent outcomes after isolated hip arthroscopy compared to normal hips at short-term follow-up [143]. Concomitant peri-acetabular osteotomy and arthroscopy versus isolated arthroscopy with capsular plication for borderline dysplasia show favorable results with similar revision/conversion rates at minimum 2-year follow-up [146]. A lower conversion to THA rate was seen in patients undergoing capsulotomy repair versus nonrepair in FAI patients with labral repair [159]. The high incidence of significant articular damage observed during arthroscopic intervention for FAI is concerning [160]. Revision rates declined over time after hip arthroscopy for FAI [142]. Rates of THA after hip arthroscopy were similar to prior studies, whereas revision hip arthroscopy rates were higher [158]. A time interval of <12 or >12 months between bilateral hip arthroscopy did not affect clinical outcomes or revision rates [151]. Overall complication rates were lower following arthroscopic approaches compared to open debridements in elbow arthroscopy [144]. While complications are higher in elbow arthroscopy than other joints, they can be minimized [157]. The annual incidence of total knee arthroplasty after arthroscopic surgery for osteoarthritis was updated to 2.46% (95% CI 1.68–3.25%) [162]. Further studies are required investigating PRO improvement and long-term revision/THA conversion rates in smokers undergoing hip arthroscopy [145].

Recovery

Light activity (weeks): Patients may return to driving 2 weeks postoperatively from a right-sided hip arthroscopy procedure [63]. Driving performance after right hip arthroscopy is comparable to that of individuals with normal hips, with braking parameters normalizing to the preoperative state at 1 week after simple arthroscopy and 2 weeks after FAI surgery [94]. The arthroscopic technique for chronic lateral epicondylitis offers advantages of earlier return to work and a shorter recovery period compared to open techniques [19].

Full activity (months): The majority of improvement after hip arthroscopy for FAI occurs within 3 months, but certain outcomes such as returning to sport, quality of life, and pain can continue to improve through 2 years [101]. Patients with untreated FAIS-related symptoms lasting 2 years or longer before arthroscopic management had significantly worse patient-reported outcomes and higher rates of reoperation at 2 years after surgery compared with those with shorter preoperative symptom duration [12]. Most patients achieved successful clinically meaningful outcomes after arthroscopic repair of circumferential labral tears at a mean follow-up of approximately 5 years [83]. The majority of patients achieve clinically significant outcome improvement at 5-year follow-up after arthroscopic FAIS surgery [97].

Complete recovery / outcome plateau (months): Master athletes undergoing primary hip arthroscopy for FAI achieve comparable patient-reported outcomes, achievement of clinically significant outcomes, and reoperation-free time-dependent survivorship to nonmaster athletes at long-term follow-up (mean 10 years) [117]. Master athletes older than age 40 undergoing primary hip arthroscopy had comparable magnitudes of improvement in patient-reported outcomes to controls, with master athletes meeting clinically meaningful thresholds at higher rates and having higher arthroplasty-free survivorship [126]. High-level athletes competing in flexibility sports demonstrated similar improvements in outcome scores and comparable rates of return to sports at minimum 2-year follow-up after hip arthroscopy [128]. Revision hip arthroscopy in high-level athletes showed significant improvement in functional scores and a high rate of successful outcomes, though patients achieved lower postoperative PRO scores and attempted to return to sport at lower rates compared to primary surgery [129]. Patients undergoing revision posterior labral repair experienced improvements in outcomes and a decrease in pain on average, but exhibited lower rates of return to active-duty and sports compared to those who underwent primary procedure [85].

Rehabilitation protocol: An accelerated rehabilitation program can be practiced after fully arthroscopic repair for chronic lateral instability of the ankle, resulting in fewer complications [46]. Closed intramedullary derotational osteotomy and hip arthroscopy for cam FAI from femoral retroversion permits rapid institution of weight-bearing ambulation and an early rehabilitative program [75]. Patients following a comprehensive five-phase rehabilitation protocol after hip arthroscopy for FAI demonstrated satisfactory clinical and functional outcomes [76]. Similar rehabilitation protocols are supported for patients with and without GLAD lesions following arthroscopic stabilization for first-time anterior shoulder instability [77]. A physical therapy regimen prior to surgical intervention may not be necessary for surgical treatment of rotator cuff tears with adhesive capsulitis [73].

Functional milestones: Arthroscopic hip revision surgery for residual FAI leads to significantly improved outcome measures with appropriate indications and expectations [3]. Smaller studies that include second-look arthroscopy provide the most convincing evidence for the efficacy of combined procedures [4]. In patients undergoing arthroscopic treatment of posterior shoulder instability, low recurrence rates and good functional outcomes were seen in >90% of patients, and 98% returned to sport activity [124]. Arthroscopic Latarjet with capsular repair resulted in a clinically meaningful change in patient's functional outcome for recurrent anterior glenohumeral instability [131]. The early clinical outcome of arthroscopic offset restoration and debridement is good in patients with no or only mild osteoarthritis [138]. Primary repair of the acetabular labrum showed good clinical results with favorable outcomes and evidence of good healing, even among patients who required repeat arthroscopy [153].

Other Considerations: Nonoperative treatment remains the first line of treatment for most FAI patients, including adolescents, and hip arthroscopy is appropriate only after failure to improve after a full course of physical therapy [20]. The objectives of surgical treatment for FAI are to improve symptoms and prevent or slow the progression of osteoarthritis by improving joint clearance [44]. Arthroscopic correction of FAI can result in significant improvement but does not invariably result in full restoration of function due to the possibility of residual symptoms from cumulative damage [147]. More prospective studies comparing open and arthroscopic excision of ganglion cysts are needed to delineate if there is a true functional benefit [24]. Innominate osteotomy for congenital hip dislocation and subluxation provides immediate stability, increases the area of articular cartilage contact, and permits early resumption of function [78]. Direct, open elevation of the tibial plateau allows restoration of much of the gross depression of the medial articular surface in the treatment of Blount disease [132].

Key Evidence

• [L3] The arthroscopic findings prior to osteotomy appeared to have little, if any, predictive value in evaluating patients for this procedure. (10.2106/00004623-198365010-00006)
• [L4] Hip arthroscopy after prior pelvic osteotomy improves outcomes, but there is insufficient evidence that adjunctive arthroscopy with osteotomy yields superior results compared to osteotomy alone. (10.1016/j.arthro.2018.07.048)
• [L3] With appropriate indications and expectations, arthroscopic hip revision surgery for residual FAI led to significantly improved outcome measures. (10.1177/2325967114s00011)
• [L5] The authors believe that smaller studies that include second-look arthroscopy provide the most convincing evidence for the efficacy of these combined procedures. (10.1016/j.arthro.2017.01.005)
• [L4] Arthroscopic intervention serves as an appropriate modality for addressing this pathology in patients with continued symptoms. (10.1016/j.arthro.2008.04.059)
• [L4] The arthroscopic method had surgical outcomes equal to or better than the other methods with a lower rate of major complications when performed by experienced surgeons. (10.1016/j.arthro.2010.09.011)
• [L5] The paper reviews the evolution of clinical and scientific foundations of osteotomy, concluding that the procedure's role in the contemporary surgical treatment of osteoarthritis may be better defined by understanding its mechanical and cellular basis. (10.2106/00004623-198466010-00024)
• [L4] Arthroscopy may be necessary to substantiate the diagnosis, as well as to assess and address other accompanying damage. (10.1016/j.arthro.2013.08.002)
• [L5] With the modification of techniques such as pelvic osteotomy and the introduction of intracapsular procedures, previously unexpected options for the surgical treatment of sequelae of childhood conditions and femoroacetabular impingement have become available. (10.1302/0301-620x.96b1.32823)
• [L5] The routine use of arthroscopy has led to the identification of previously unrecognized pathological conditions and significant new information about traditional problems. (10.2106/00004623-198365030-00027)
• [L4] These findings suggest that hip dysplasia may not be an absolute contraindication for isolated hip arthroscopy and may serve as a viable intervention with consideration of staged future periacetabular osteotomy (PAO). (10.1177/03635465231197177)
• [L3] Patients with untreated, FAIS-related symptoms lasting 2 years or longer before arthroscopic management had significantly worse patient-reported outcomes and higher rates of reoperation at 2 years after surgery when compared with those patients with a shorter duration of preoperative symptoms. (10.1177/0363546518808046)
• [L4] Arthroscopic management of patients with FAI results in significant improvement in outcomes measures and the 'impingement' sign at early term follow-up. (10.1016/j.arthro.2007.03.029)
• [L4] The arthroscopist should inform the patient that even in absence of radiographic OA, the probability of extensive articular damage does exist. (10.1016/j.arthro.2013.09.014)
• [L5] This case report presents the youngest patient treated arthroscopically for this condition with successful outcomes. (10.1007/s00167-014-2978-5)
• [L4] Arthroscopic decompression of a symptomatic AIIS deformity is a reproducible procedure that can provide excellent outcomes at short-term follow-up. (10.1016/j.arthro.2012.05.882)
• [L5] The procedure requires accurate placement of portals and small instrumentation to examine, probe, and treat intra-articular abnormalities. (10.2106/00004623-199908000-00015)
• [L4] The available information is not sufficient to support one treatment modality over another, and the answers regarding the interchangeability of arthroscopy and surgical dislocation remain unclear. (10.1016/j.arthro.2013.10.005)
• [L3] The arthroscopic technique offers advantages of earlier return to work and shorter recovery period along with additional advantages of joint inspection and ability to treat coexisting pathologies. (10.1016/j.asmr.2020.07.010)
• [L5] Nonoperative treatment remains the first line of treatment for most FAI patients and should not be abandoned in favor of early surgery; hip arthroscopy is an appropriate viable option only after failure to improve after a full course of physical therapy is established. (10.1016/j.arthro.2023.05.009)
• [L4] Appropriate surgical indications based on preoperative intra-articular cartilage degeneration are paramount to achieving long-term success in PAO. (10.1016/j.arthro.2021.01.060)
• [L4] The procedure had minimal complications, provided considerable pain relief in 80% of patients, and helped avoid major revision arthroplasty surgery in 100% of cases. (10.1016/j.asmr.2025.101262)
• [L1] The utilization of arthroscopy resulted in superior outcomes with a reduced incidence of complications, although in certain instances, the mini open technique demonstrated comparable efficacy to arthroscopy. (10.1177/2325967124s00424)
• [L4] More prospective studies comparing open and arthroscopic excision are needed to delineate if there is a true functional benefit. (10.1016/j.hcl.2013.08.020)
• [L1] The authors do not recommend arthroscopy in cases of evolved osteoarthritis. (10.5435/jaaos-d-17-00380)
• [Paper] Arthroscopic techniques, in comparison to open techniques, have a lower major complication rate, decreased morbidity, and equivalent patient outcomes at short-term and midterm follow-up. (10.1016/j.eats.2013.08.007)
• [L4] However, the procedure is technically more difficult than the regular Salter osteotomy and is not intended to routinely replace it. (10.2106/00004623-198264020-00005)
• [L4] The authors recommend using biomechanical analysis as an adjunct to clinical decision-making for treating dysplastic hips. (10.2106/00004623-199606000-00008)
• [L5] Dynamic changes in pelvic tilt significantly influence the functional orientation of the acetabulum and must be considered. (10.1177/0363546514541229)
• [L1] Biomechanical evidence supports closure of the capsule after hip arthroscopy to reverse the significant effects of capsulotomy. (10.1016/j.arthro.2021.04.004)
• [L5] Lumbopelvic stability and restoring appropriate hip biomechanics and muscle firing patterns are key to successful return to activity and sport. (10.1002/arj.70175)
• [L5] Painless restoration of normal hip biomechanics should be the goal of clinical correction of labral dysfunction through labral debridement, labral repair, or labral reconstruction. (10.1016/j.csm.2016.02.004)
• [L3] Three-dimensional kinematic analysis detects changes due to HTO that standard radiographs do not identify, including changes in the PF joint. (10.1016/j.arthro.2013.07.039)
• [Case_report] In patients with risk factors such as altered biomechanics from knee procedures, hip pain or stiffness may indicate a stress fracture of the ipsilateral femoral neck, as early radiographs may be negative. (10.2106/00004623-198264020-00030)
• [L3] The Delta Angle (DA) can be reliably measured and serves as a valuable supportive parameter in the assessment of hip microinstability. (10.1186/s12891-025-09267-7)
• [L4] However, judicious use of arthroscopic surgery is appropriate for managing symptomatic coexisting disease or abnormality in the presence of OA or degeneration. (10.1177/2325967118756597)
• [L3] A substantial force is required to achieve and maintain hip distraction, with males requiring higher forces. (10.1177/2325967118s00151)
• [Paper] The described technique is recommended for all surgeons familiar with arthroscopic surgery. (10.1007/s00402-009-0882-0)
• [Paper] However, ongoing efforts to achieve a more precise understanding of each patient's unique pathomechanics and joint health will be mandatory to reliably alter the natural history of hip osteoarthritis. (10.2106/jbjs.26.00299)
• [L5] The objectives of surgical treatment are to improve symptoms and prevent or slow the progression of osteoarthritis by improving joint clearance. (10.1016/j.otsr.2012.06.001)
• [L5] The authors conclude that there is no single 'right way' to be an expert arthroscopist, as varied approaches and techniques among luminaries all yield superb patient outcomes. (10.1016/j.arthro.2007.08.035)
• [L4] An accelerated rehabilitation program can be practiced and fewer complications arise, since it is a fully arthroscopic procedure. (10.1016/j.arthro.2008.04.061)
• [L4] This procedure is an effective, less invasive alternative to TRO for patients with extensive necrosis who would have otherwise required rotational osteotomy. (10.1186/s13018-024-04951-1)
• [L3] It successfully prevents and slows the progression of knee osteoarthritis by changing the contact biomechanics. (10.1177/2325967123s00248)
• [L4] Despite reduction of the hip for long periods of time, acetabular remodeling did not occur. (10.2106/00004623-198567080-00014)
• [L5] Arthroscopy provides a powerful tool to successfully treat intra-articular hip pathology secondary to dysplasia while improving the bony coverage/alignment with periacetabular osteotomy; through a specialized team approach, all relevant pathology can be addressed and successful outcomes achieved. (10.1016/j.arthro.2018.11.042)
• [L3] With careful selection and modern techniques, patients with dysplasia can benefit significantly and durably from arthroscopic labral repair. (10.1177/0363546518767399)
• [L4] High rates of FAI morphologic characteristics are present in patients with hip instability. (10.1016/j.arthro.2015.07.021)
• [L3] Knee arthroscopy is not a benign procedure, and surgeons should be aware of procedure complexity, patient factors, and regional differences to reduce complications. (10.1177/2325967113s00044)
• [L3] The classification system demonstrated that a higher tear type (increasing displacement of the tear gap in arthroscopic surgery) is associated with higher meniscal extrusion, severe chondral wear, and greater severity of arthritis. (10.1177/2325967119827945)
• [L4] The main indication for hip arthroscopy today is FAI. (10.1177/2325967114s00133)
• [L5] From biomechanics points, RAO was more effective in relieving hip joint stress compared with shelf procedure and Chiari osteotomy. (10.1186/1471-2474-15-47)
• [L3] A clinical diagnosis of hip osteoarthritis was found in approximately 22% of young patients undergoing hip arthroscopy within 2 years. (10.1186/s12891-019-2646-5)
• [L3] This study reports favorable outcomes of arthroscopic management of FAI in adolescents with results more than comparable to those of an adult population. (10.1016/j.arthro.2013.09.055)
• [L4] Knee arthroscopy is effective in treating patients with symptomatic osteoarthritis and mechanical symptoms, with 76% reporting good and excellent results. (10.1016/j.arthro.2011.03.031)
• [L4] This study's findings suggest that patients may return to driving 2 weeks postoperatively from a right sided hip arthroscopy procedure. (10.1016/j.arthro.2017.08.185)
• [L2] Intraarticular injections of local anaesthetics seem to provide an alternative and effective solution in pain control after knee arthroscopy. (10.1186/1749-799x-1-17)
• [L5] The authors encourage thorough preoperative evaluation of radiographs and advanced imaging for all patients being considered for hip arthroscopy. (10.5435/jaaos-d-16-00231)
• [L5] This statement outlines suggested guidelines for the practice of arthroscopic surgery, emphasizing the need for appropriate training, privileges, and performance review by the Arthroscopy Association of North America. (10.1016/s0749-8063(18)30012-4)
• [L5] This statement outlines suggested guidelines for the practice of arthroscopic surgery, emphasizing the need for appropriate training, privileges, and performance review by the Arthroscopy Association of North America. (10.1016/s0749-8063(16)30959-8)
• [L5] This statement outlines suggested guidelines for the practice of arthroscopic surgery, emphasizing the need for appropriate training, privileges, and performance review by the Arthroscopy Association of North America. (10.1016/s0749-8063(15)00394-1)
• [L1] It is a safe intervention that allows for efficient postoperative analgesia for patients undergoing hip arthroscopy. (10.1177/0363546520943580)
• [L4] Arthroscopic surgery performed in selected patients over 50 years of age might be beneficial if classified as Tönnis grade 0 preoperatively and/or classified as Outerbridge grade II in the arthroscopic findings. (10.1186/s13018-016-0504-9)
• [L5] The combination of hip arthroscopy and periacetabular osteotomy is safe and effective, but clearer definitions for labral pathology and indications for repair or debridement are required. (10.1016/j.arthro.2025.01.002)
• [L1] A physical therapy regimen prior to surgical intervention may not be necessary. (10.1016/j.arthro.2017.08.218)
• [L4] Even among a group of high-volume hip arthroscopists who engaged in several discussions about the proposed classification schemes, grades were found to have at best moderate interrater reliability. (10.1007/s00167-020-06215-x)
• [Paper] The surgery permits rapid institution of weight-bearing ambulation and an early rehabilitative program. (10.1016/j.eats.2013.08.013)
• [L4] Patients following this rehabilitation protocol after hip arthroscopy demonstrated satisfactory clinical and functional outcomes, validating its implementation. (10.1007/s00167-013-2664-z)
• [L4] These results support similar rehabilitation protocols for those with and without GLAD lesions following arthroscopic stabilization. (10.1177/2325967125s00145)
• [L4] The procedure provides immediate stability, increases the area of articular cartilage contact, and permits early resumption of function. (10.2106/00004623-196648070-00016)
• [L3] This rate of complications is in line with complication rates after open surgical dislocation using the same classification system. (10.1177/2325967113s00045)
• [L3] This rate of complications is in line with complication rates after open surgical dislocation using the same classification system. (10.1016/j.arthro.2013.09.046)
• [L3] Favorable outcomes of arthroscopic management of FAI in adolescents are reported compared with an adult control group. (10.1016/j.arthro.2016.02.019)
• [L5] It emphasizes that while conservative treatment is the initial approach, arthroscopy is a standardized procedure with numerous indications for posterior pathology when conservative measures fail. (10.1136/jisakos-2016-000082)
• [L4] Most patients achieved successful clinically meaningful outcomes after arthroscopic repair at a mean follow-up of approximately 5 years. (10.1177/23259671261418674)
• [L4] This classification system allows for the ability to evaluate differing repair patterns and their effects on postoperative clinical outcomes. (10.1177/2325967125s00101)
• [L4] While patients who underwent revision PLR experienced improvements in outcomes and a decrease in pain on average, they exhibited rates of return to active-duty and sports that lagged behind those demonstrated in a previous cohort that underwent a primary procedure. (10.1177/23259671251322695)
• [L5] Non-operative treatment cannot correct the deformity but can help control symptoms. (10.1302/2058-5241.1.000005)
• [L3] A preoperative femoral nerve block is a relatively safe procedure that may decrease the requirement for intraoperative morphine while providing effective postoperative pain control in patients undergoing hip arthroscopic surgery. (10.1177/0363546513510392)
• [L5] Surgeons should view these systems as valuable adjuncts rather than replacements for traditional osteotomies, and must remain vigilant in case selection and intraoperative execution. (10.2106/jbjs.25.01155)
• [L3] Among patients requiring reoperation for intra-articular defects, the average time to reoperation was nearly 5 months shorter for patients receiving arthroscopy than for patients who did not receive arthroscopy. (10.1177/2325967119s00325)
• [L5] The number of indications for anterior ankle arthroscopy is rising, and open surgery is increasingly replaced by arthroscopic surgery. (10.1136/jisakos-2015-000009)
• [L1] Risk factors include leakage of arthroscopy fluid, use of a thermal device, intra-articular anesthetics/pain pumps, and performing specific surgical procedures. (10.1016/j.asmr.2020.12.002)
• [L3] Driving performance of patients who underwent right hip arthroscopy is comparable to that of individuals with normal hips, and braking parameters normalize to the preoperative state at 1 week after simple arthroscopy and 2 weeks after FAI surgery. (10.1186/s12891-020-03662-y)
• [L4] The arthroscopic resection is effective and safe if conservative treatment fails. (10.1302/2058-5241.5.200027)
• [L3] The majority of patients achieve clinically significant outcome improvement at 5-year follow-up after arthroscopic FAIS surgery. (10.1016/j.arthro.2021.02.033)
• [L3] Moreover, preoperative MRI delayed time to arthroscopy. (10.1016/j.arthro.2022.03.025)
• [L4] The rate of short-term complications, in particular the risk of DVT and PE after this operation, is low. (10.1016/j.arthro.2014.12.013)
• [L3] Hip arthroscopy for the treatment of FAIS in competitive athletes and nonathletes produced clinically meaningful outcomes in both patient groups. (10.1177/0363546519885359)
• [L4] The majority of improvement occurs within 3 months after surgery, but certain outcomes, such as returning to sport, QoL, and pain, can continue to improve through 2 years. (10.1177/0363546518795696)
• [L4] Combined treatment of non-arthritic hip dysplasia with hip arthroscopy and PAO obtained good clinical and radiological outcomes. (10.1177/2325967117s00015)
• [L4] In patients with a normal MRI without contrast and a positive response to an intra-articular injection that failed conservative management, there is a 98% chance of intra-articular hip pathology being discovered on hip arthroscopy. (10.1186/s12891-017-1485-5)
• [L3] Arthroscopically assisted may have the ability to identify concomitant injuries not initially seen on imaging or when a complete imaging evaluation is not available. (10.1177/2325967125s00151)
• [L5] Gadolinium intra-articular contrast magnetic resonance imaging is not required for every patient undergoing hip arthroscopy, but contrast magnetic resonance imaging plus computed tomography with 3-dimensional reconstruction are essential for patients requiring revision. (10.1016/j.arthro.2022.12.008)
• [L4] The findings of this study demonstrate post-surgical radiographic and anatomical evidence of capsular defects in a select group of patients following hip arthroscopy. (10.1007/s00167-013-2591-z)
• [L4] A non-physeal-sparing arthroscopic approach for FAI in adolescents with open physes is safe and effective with no evidence of clinically relevant complication of growth arrest-related deformity or physeal instability in patients with a minimum of 1 year of follow-up after surgery. (10.1016/j.arthro.2019.01.029)
• [L3] The incidence of symptomatic postoperative VTE following hip arthroscopy is low. (10.1016/j.arthro.2019.03.054)
• [L4] Arthroscopic stabilization with resorbable devices is a highly reliable procedure that is, however, not devoid of complications. (10.1177/2325967115586559)
• [L3] There are distinct differences in thrombosis risk per person after knee arthroscopy. (10.1016/j.arthro.2017.08.113)
• [L4] From the patients' point of view, the most gratifying aspect of the surgery was relief of pain. (10.2106/00004623-199274060-00020)
• [L5] The author argues that routine preoperative MRI for hip arthroscopy is unnecessary for patients with typical symptoms and findings, as it delays surgical intervention and increases costs without altering surgical decision-making. (10.1016/j.arthro.2022.04.009)
• [L3] More than one half of patients undergoing revision hip arthroscopy had MRI and intraoperative evidence of capsular incompetency. (10.1016/j.arthro.2019.07.026)
• [L4] The low incidence of VTE events found in this review (2.0%) suggests that prophylaxis may not be necessary in low-risk patients undergoing hip arthroscopy; however, the true rate may be under-reported. (10.1016/j.arthro.2017.07.006)
• [L4] MRI at 1 year after surgery demonstrated residual tear evidence for all patients. (10.1016/j.asmr.2021.08.003)
• [L4] The progression of osteoarthritis after rotational acetabular osteotomy was not detected for at least twenty years in most hips with either pre-osteoarthritis or initial osteoarthritis in this cohort. (10.2106/jbjs.n.00667)
• [L3] Master athletes undergoing primary hip arthroscopy for femoroacetabular impingement syndrome achieve comparable patient-reported outcomes, achievement of clinically significant outcomes, and reoperation-free time-dependent survivorship to nonmaster athletes at long-term follow-up. (10.1177/03635465251395219)
• [L4] Osteotomy fixation with 3 proximal and 3 distal screws was associated with osteotomy healing. (10.1016/j.arthro.2014.04.013)
• [L4] Additional complications relating to surgical technique, such as suture anchors and femoral osteoplasty, arose as more complex procedures were performed. (10.1016/j.arthro.2014.03.017)
• [L4] Thromboembolic complications do occur after elective hip arthroscopy. (10.1007/s00167-010-1392-x)
• [L4] Using this technique, patients showed significant clinical improvement and no postoperative instability at 1 and 2 years after surgery. (10.1016/j.arthro.2018.10.142)
• [Paper] Arthroscopic removal of troublesome screws can successfully be achieved, affording the benefits of minimally invasive surgery and the ability to address concomitant hip pathology. (10.1016/j.eats.2014.05.013)
• [L5] Osteotomy should be the first operation considered in a young individual with osteo-arthritis of the hip, performed before there is collapse of the head or reduction of the range of flexion below 90 degrees. (10.2106/00004623-196446060-00020)
• [L4] In addition, low recurrence rates and good functional outcomes were seen in >90% of the patients, and 98% returned to sport activity. (10.1177/2325967120969151)
• [L3] However, the magnitudes of improvement in patient-reported outcomes were comparable between the groups, with master athletes meeting clinically meaningful thresholds at higher rates and having higher arthroplasty-free survivorship. (10.1177/03635465251407118)
• [L4] In this analysis, 2,640 arthroscopic procedures had an 8.2 per cent complication rate. (10.2106/00004623-198668020-00011)
• [L3] Despite this, both groups demonstrated similar improvements in outcome scores and comparable rates of return to sports at minimum 2-year follow-up. (10.1177/03635465221077002)
• [L3] The study group showed significant improvement in functional scores and a high rate of successful outcomes, though they achieved lower postoperative PRO scores and attempted to return to sport at lower rates compared to primary surgery. (10.1177/03635465211041760)
• [L3] Second-time revision hip arthroscopy results in clinically significant improvement in patient-reported outcomes; however, outcomes for repeat revision cases are similar to first-time revision cases but inferior to those obtained following primary surgeries. (10.1016/j.arthro.2021.04.031)
• [L3] These results indicate that arthroscopic Latarjet with capsular repair resulted in a clinically meaningful change in patient's functional outcome. (10.1016/j.jisako.2025.100777)
• [L4] Direct, open elevation of the tibial plateau is the essential element of this operative approach, allowing restoration of much of the gross depression of the medial articular surface. (10.2106/00004623-199274030-00005)
• [L1] Obesity, smoking, and age >45 years are found to be significant risk factors for postoperative VTE after hip arthroscopy. (10.1186/s13018-025-05536-2)
• [L3] Routine thromboprophylaxis after HA may not be indicated in all patients but can be considered based on patient-specific risk factors. (10.1016/j.arthro.2022.10.029)
• [L4] Obese patients, however, are at a significantly increased risk of postoperative complications such as DVTs and worsened hip pain. (10.1016/j.arthro.2014.07.013)
• [L3] There was no difference in the incidence of venous thromboembolic complications between patients who did and did not receive TXA preoperatively. (10.1016/j.arthro.2024.03.051)
• [L4] The early clinical outcome of arthroscopic offset restoration and debridement is good in patients with no or only mild osteoarthritis. (10.1016/j.arthro.2007.08.010)
• [L5] Arthroscopic and related surgery has a low complication rate, but surgeons must learn from complications that do occur through careful review and study of etiology and prevention. (10.1016/j.arthro.2014.08.002)
• [L2] Patients undergoing CWHTO are at risk of postoperative VTE. (10.1016/j.otsr.2017.07.016)
• [L1] All 11 studies included in this systematic review reported clinically significant functional improvements after arthroscopic labral reconstruction and low rates of complications, revision surgery, and progression of arthritis, although graft types and concomitant procedures confound the results. (10.1016/j.arthro.2019.02.031)
• [L3] There was a significant decline in revision rates over time. (10.1177/23259671251326112)
• [L1] In a meta-analysis of the available literature, patients with BDH are able to equally reach statistically similar clinical outcomes after isolated hip arthroscopy as compared with control subjects without dysplasia at short-term follow-up. (10.5435/jaaos-d-22-00302)
• [L3] Overall rates of complication were lower following arthroscopic approaches in this cohort of surgeons. (10.1177/23259671261425647)
• [L1] Further studies are required investigating the degree of PRO improvement and long-term arthroscopy revision and THA conversion rates. (10.1177/0363546520922854)
• [L3] A high percentage of patients in both groups reached clinically relevant thresholds, with similar rates of revision and conversion to arthroplasty at minimum 2-year follow-up. (10.1016/j.arthro.2025.02.032)
• [L5] Arthroscopic correction of FAI can result in significant improvement but does not invariably result in full restoration of function, as the possibility of residual symptoms is always a reality due to cumulative damage. (10.1016/j.arthro.2018.07.005)
• [L4] Although both techniques demonstrated improvement in patient-reported outcomes, the systematic review did not demonstrate clinical superiority of either technique due to study heterogeneity and low level of evidence. (10.1016/j.arthro.2021.10.016)
• [L4] The reoperation rate after revision hip arthroscopy is 5% within 2 years, including further arthroscopy or conversion to hip arthroplasty. (10.1016/j.arthro.2014.12.027)
• [L4] In this study of primary hip arthroscopy, 90-day adverse events were low at 1.28%, and the 5-year secondary surgery rate was 4.9%. (10.1016/j.arthro.2023.01.100)
• [L3] A time interval of less than 12 months or greater than 12 months between bilateral procedures did not affect clinical outcomes and revision rate. (10.1002/arj.70069)
• [L4] In this study, we found inadequate harms reporting in most systematic reviews concerning hip arthroscopy. (10.1016/j.asmr.2022.10.010)
• [L4] This study showed good clinical results of primary repair with favorable outcomes and evidence of good healing, even among the 11% of patients who required repeat arthroscopy. (10.1016/j.arthro.2014.02.007)
• [L4] The rate of major complications was 0.58% after hip arthroscopy. (10.1016/j.arthro.2012.11.003)
• [L3] The overall rate of surgical site infections is low following hip arthroscopy. (10.5435/jaaos-d-24-00262)
• [L4] Revision hip arthroscopic surgery resulted in an improvement in outcome in the first 3 years after revision, with significant improvement only in the first 2 years. (10.1007/s00167-013-2373-7)
• [L5] While complications are higher than in other joint arthroscopies, they can be minimized. (10.1136/jisakos-2016-000089)
• [L4] Rates of total hip arthroplasty were similar to prior studies, whereas the rates of revision hip arthroscopy were higher. (10.1016/j.arthro.2017.01.021)
• [L3] In addition, a lower rate of conversion to THA was seen in the repair group. (10.1016/j.arthro.2019.01.033)
• [L4] The high incidence of significant articular damage observed at the time of arthroscopic intervention is concerning. (10.1016/j.arthro.2011.05.018)
• [L5] Arthroscopy is scientifically proven, based on evidence, and will remain a central part of orthopedic research due to low risk of complications and low morbidity. (10.1136/jisakos-2017-000156)
• [L2] The annual incidence of total knee arthroplasty after arthroscopic surgery for osteoarthritis was updated to 2.46% (95% CI 1.68–3.25%). (10.1186/s12891-022-05344-3)

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[55] Complications Following Arthroscopic Knee Surgery. Orthopaedic Journal of Sports Medicine. 2013. DOI: 10.1177/2325967113s00044

[56] A Novel Arthroscopic Classification of Degenerative Medial Meniscus Posterior Root Tears Based on the Tear Gap. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119827945

[57] Indications and Results of Hip Arthroscopy in 288 Consecutive Patients with a Minimum Follow-Up of 6 Months. Orthopaedic Journal of Sports Medicine. 2014. DOI: 10.1177/2325967114s00133

[58] The biomechanical differences of rotational acetabular osteotomy, Chiari osteotomy and shelf procedure in developmental dysplasia of hip. BMC Musculoskeletal Disorders. 2014. DOI: 10.1186/1471-2474-15-47

[59] The two-year incidence of hip osteoarthritis after arthroscopic hip surgery for femoroacetabular impingement syndrome. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2646-5

[60] Comparison between Classical and Less Invasive Technique for Arthroscopic Surgery in FAI. Arthroscopy. 2013. DOI: 10.1016/j.arthro.2013.09.055

[61] Patient_and_Disease_Characteristics_Associated_with_Hip_Arthroscopy_Failure_in_A_S0883540314003489. n.d..

[62] Histological Analysis of Tissue Ingrowth and Organization Following Implantation of a Novel Synthetic Acellular Meniscal Scaffold for the Treatment of Irreparable Partial Meniscus Tears and/or Partial (SS‐27A). Arthroscopy. 2011. DOI: 10.1016/j.arthro.2011.03.031

[63] Paper #222: Return to Driving After Hip Arthroscopy. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.08.185

[64] The intra-articular use of ropivacaine for the control of post knee arthroscopy pain. Journal of Orthopaedic Surgery and Research. 2006. DOI: 10.1186/1749-799x-1-17

[66] Iatrogenic Hip Instability Treated With Periacetabular Osteotomy. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-16-00231

[67] Suggested Guidelines for the Practice of Arthroscopic Surgery. Arthroscopy. 2018. DOI: 10.1016/s0749-8063(18)30012-4

[68] Suggested Guidelines for the Practice of Arthroscopic Surgery. Arthroscopy. 2017. DOI: 10.1016/s0749-8063(16)30959-8

[69] Suggested Guidelines for the Practice of Arthroscopic Surgery. Arthroscopy. 2015. DOI: 10.1016/s0749-8063(15)00394-1

[70] Prospective Single-Blinded Randomized Controlled Trial Comparing Pericapsular Injection Versus Lumbar Plexus Peripheral Nerve Block for Hip Arthroscopy. The American Journal of Sports Medicine. 2020. DOI: 10.1177/0363546520943580

[71] Clinical results of arthroscopic surgery in patients over 50 years of age—what viability does it have as a joint preservative surgery?. Journal of Orthopaedic Surgery and Research. 2017. DOI: 10.1186/s13018-016-0504-9

[72] Editorial Commentary : Indications for Performing Hip Arthroscopy in Addition to Periacetabular Osteotomy for the Treatment of Developmental Dysplasia of the Hip Require Clarification. Arthroscopy. 2025. DOI: 10.1016/j.arthro.2025.01.002

[73] Paper #256: Outcomes Following Surgical Treatment for Rotator Cuff Tears with Adhesive Capsulitis are Equivalent to Surgical Treatment for Rotator Cuff Tears Alone: A Systematic Review. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.08.218

[74] Arthroscopic classification of intra‐articular hip pathology demonstrates at best moderate interrater reliability. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06215-x

[75] Closed Intramedullary Derotational Osteotomy and Hip Arthroscopy for Cam Femoroacetabular Impingement From Femoral Retroversion. Arthroscopy Techniques. 2014. DOI: 10.1016/j.eats.2013.08.013

[76] A comprehensive five‐phase rehabilitation programme after hip arthroscopy for femoroacetabular impingement. Knee Surgery, Sports Traumatology, Arthroscopy. 2013. DOI: 10.1007/s00167-013-2664-z

[77] Poster 33: Clinical Outcomes Of Glenoid Labral Articular Disruption (GLAD) Lesions in the Setting of First-Time Anterior Shoulder Instability Events. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/2325967125s00145

[78] Role of Innominate Osteotomy in the Treatment of Congenital Dislocation and Subluxation of the Hip in the Older Child. The Journal of Bone & Joint Surgery. 1966. DOI: 10.2106/00004623-196648070-00016

[79] Complications after Hip Arthroscopy. Orthopaedic Journal of Sports Medicine. 2013. DOI: 10.1177/2325967113s00045

[80] Complications after Hip Arthroscopy: A Prospective, Multicenter Study Using a Validated Grading Classification. Arthroscopy. 2013. DOI: 10.1016/j.arthro.2013.09.046

[81] Arthroscopic Management of Femoroacetabular Impingement in Adolescents. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2016.02.019

[82] Posterior ankle arthroscopy: current state of the art. Journal of ISAKOS. 2017. DOI: 10.1136/jisakos-2016-000082

[83] Circumferential Labral Tears: Instability History and Outcomes of Arthroscopic Repair. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261418674

[84] Paper 44: Medial Meniscus Ramp Tears: An Internationally Developed Surgically Relevant Classification System Based on Tear Morphology. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/2325967125s00101

[85] Midterm Outcomes After Revision Posterior Labral Repair in Active-Duty Military Patients. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/23259671251322695

[86] Treatment of hallux valgus deformity. EFORT Open Reviews. 2016. DOI: 10.1302/2058-5241.1.000005

[88] Preoperative Femoral Nerve Block in Hip Arthroscopic Surgery. The American Journal of Sports Medicine. 2013. DOI: 10.1177/0363546513510392

[89] Evolving Strategies for Cementless Stem Removal in Revision Total Hip Arthroplasty. Journal of Bone and Joint Surgery. 2026. DOI: 10.2106/jbjs.25.01155

[90] Arthroscopy in Lateral Ankle Ligament Stabilization Surgery: Costs, Complications, Intra-Articular Defect Diagnosis, and Reoperations. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119s00325

[91] Anterior ankle arthroscopy: state of the art. Journal of ISAKOS. 2016. DOI: 10.1136/jisakos-2015-000009

[93] Heat‐Related Complications from Radiofrequency and Electrocautery Devices Used in Arthroscopic Surgery: A Systematic Review. Arthroscopy, Sports Medicine, and Rehabilitation. 2021. DOI: 10.1016/j.asmr.2020.12.002

[94] Time taken to resume driving following hip arthroscopy. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03662-y

[96] Synovial plica of the elbow and its clinical relevance. EFORT Open Reviews. 2020. DOI: 10.1302/2058-5241.5.200027

[97] Gender and Age-Specific Differences Observed in Rates of Achieving Meaningful Clinical Outcomes 5-Years After Hip Arthroscopy for Femoroacetabular Impingement Syndrome. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021. DOI: 10.1016/j.arthro.2021.02.033

[98] Preoperative Magnetic Resonance Imaging Offers Questionable Clinical Utility, Delays Time to Hip Arthroscopy, and Lacks Cost‐Effectiveness in Patients Aged ≤40 Years With Femoroacetabular Impingement Syndrome: A Retrospective 5‐Year Analysis. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.03.025

[99] Complications and Survival Analyses of Hip Arthroscopies Performed in the National Health Service in England: A Review of 6,395 Cases. Arthroscopy. 2015. DOI: 10.1016/j.arthro.2014.12.013

[100] Comparing Outcomes of Competitive Athletes Versus Nonathletes Undergoing Hip Arthroscopy for Treatment of Femoroacetabular Impingement Syndrome. The American Journal of Sports Medicine. 2019. DOI: 10.1177/0363546519885359

[101] When Do Patients Improve After Hip Arthroscopy for Femoroacetabular Impingement? A Prospective Cohort Analysis. The American Journal of Sports Medicine. 2018. DOI: 10.1177/0363546518795696

[102] One stage hip arthroscopy and periacetabular osteotomy: surgical technique and initial results. Orthopaedic Journal of Sports Medicine. 2017. DOI: 10.1177/2325967117s00015

[103] Arthroscopic findings of a diagnostic dilemma- hip pathology with normal imaging. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1485-5

[104] Poster 40: Arthroscopically Assisted Versus Open Procedures for the Management of Acromioclavicular Joint Dislocation: A Comparative Study. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/2325967125s00151

[105] Editorial Commentary : Gadolinium Intra‐Articular Contrast Magnetic Resonance Imaging Is Not Required for Every Patient Undergoing Hip Arthroscopy, but Contrast Magnetic Resonance Imaging Plus Computed Tomography With 3‐Dimensional Reconstruction Are Essential for Patients Requiring Revision. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2022.12.008

[106] Evidence of capsular defect following hip arthroscopy. Knee Surgery, Sports Traumatology, Arthroscopy. 2013. DOI: 10.1007/s00167-013-2591-z

[107] Arthroscopic Surgery for Femoroacetabular Impingement in Skeletally Immature Athletes: Radiographic and Clinical Analysis. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2019.01.029

[108] Incidence and Risk Factors for Venous Thromboembolism Following Hip Arthroscopy: A Population‐Based Study. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2019.03.054

[109] Anterior Glenoid Rim Fracture Following Use of Resorbable Devices for Glenohumeral Stabilization. Orthopaedic Journal of Sports Medicine. 2015. DOI: 10.1177/2325967115586559

[110] Paper #150: Risk Factors Analysis of Venous Thromboembolism Events after Knee Arthroscopy: A Case‐Control Study. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.08.113

[111] Pigmented villonodular synovitis of the knee. The results of total arthroscopic synovectomy, partial arthroscopic synovectomy, and arthroscopic local excision.. The Journal of Bone & Joint Surgery. 1992. DOI: 10.2106/00004623-199274060-00020

[112] Editorial Commentary: Routine Preoperative Magnetic Resonance Imaging for Hip Arthroscopy Is Wasting Health Care Dollars and Delaying Surgical Intervention: Decision Making Should Be at the Discretion of the Health Care Provider Not Mandated by Health Care Insurers. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.04.009

[113] Two-Year Patient-Reported Outcomes for Patients Undergoing Revision Hip Arthroscopy with Capsular Incompetency. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2020. DOI: 10.1016/j.arthro.2019.07.026

[114] Venous Thromboembolism Events After Hip Arthroscopy: A Systematic Review. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.07.006

[115] In‐Office Needle Arthroscopy Can Evaluate Meniscus Tear Repair Healing as an Alternative to Magnetic Resonance Imaging. Arthroscopy, Sports Medicine, and Rehabilitation. 2021. DOI: 10.1016/j.asmr.2021.08.003

[116] Rotational Acetabular Osteotomy for Osteoarthritis with Acetabular Dysplasia. The Journal of Bone and Joint Surgery-American Volume. 2015. DOI: 10.2106/jbjs.n.00667

[117] Long-term Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome in Master Athletes: A Propensity-Matched Study With Mean 10-Year Follow-up. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465251395219

[118] Opening‐Wedge High Tibial Osteotomy: Results of 100 Consecutive Cases. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2014.04.013

[119] Hip Arthroscopy for Femoroacetabular Impingement: The Changing Nature and Severity of Associated Complications Over Time. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2014.03.017

[120] Pulmonary embolism after hip arthroscopy. Knee Surgery, Sports Traumatology, Arthroscopy. 2011. DOI: 10.1007/s00167-010-1392-x

[121] Periportal Capsulotomy: Technique and Outcomes for a Limited Capsulotomy During Hip Arthroscopy. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2019. DOI: 10.1016/j.arthro.2018.10.142

[122] Arthroscopic Treatment of Slipped Capital Femoral Epiphysis Screw Impingement and Concomitant Hip Pathology. Arthroscopy Techniques. 2014. DOI: 10.1016/j.eats.2014.05.013

[123] Osteotomy in the Treatment of Osteo-Arthritis of the Hip. The Journal of Bone & Joint Surgery. 1964. DOI: 10.2106/00004623-196446060-00020

[124] Return to Sport After Arthroscopic Treatment of Posterior Shoulder Instability. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120969151

[126] Midterm Outcomes of Primary Hip Arthroscopy in Athletes Older Than Age 40: A Propensity-Matched Controlled Study. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465251407118

[127] Arthroscopy--'no-problem surgery'. An analysis of complications in two thousand six hundred and forty cases.. The Journal of Bone & Joint Surgery. 1986. DOI: 10.2106/00004623-198668020-00011

[128] Pathologic Findings on Hip Arthroscopy in High-Level Athletes Competing in Flexibility Sports. The American Journal of Sports Medicine. 2022. DOI: 10.1177/03635465221077002

[129] Revision Hip Arthroscopy in High-Level Athletes: Minimum 2-Year Outcomes Comparison to a Propensity-Matched Primary Hip Arthroscopy Control Group. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211041760

[130] Repeat Revision Hip Arthroscopy Outcomes Match That of Initial Revision But Not That of Primary Surgery for Femoroacetabular Impingement Syndrome. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021. DOI: 10.1016/j.arthro.2021.04.031

[131] Evaluation of Kinesiophobia in Patients Treated With Arthroscopic Bankart Repair for Recurrent Anterior Glenohumeral Instability. Journal of ISAKOS. 2025. DOI: 10.1016/j.jisako.2025.100777

[132] Elevation of the medical plateau of the tibia in the treatment of Blount disease.. The Journal of Bone & Joint Surgery. 1992. DOI: 10.2106/00004623-199274030-00005

[133] Risk factors for venous thromboembolism after hip arthroscopy: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05536-2

[134] Incidence of Venous Thromboembolism After Hip Arthroscopy Is Low With or Without Prophylaxis but Risk Factors Include Oral Contraceptive Use, Obesity, and Malignancy. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.10.029

[135] PAUL TORNETTA III EDITOR, VOL. 61. 2011.

[136] Correlation of Obesity With Patient‐Reported Outcomes and Complications After Hip Arthroscopy. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2014.07.013

[137] Single‐Dose Intravenous Tranexamic Acid Does Not Increase Venous Thromboembolic Rate or Complication Rate During Hip Arthroscopy. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.03.051

[138] Arthroscopic Offset Restoration in Femoroacetabular Cam Impingement: Accuracy and Early Clinical Outcome. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2007.08.010

[139] Hip Arthroscopy Dislocation and Shoulder Arthroscopy Positioning. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2014.08.002

[140] Edoxaban is effective in reducing the incidence of asymptomatic phlebographic events following closed-wedge high tibial osteotomy. Orthopaedics & Traumatology: Surgery & Research. 2017. DOI: 10.1016/j.otsr.2017.07.016

[141] Indications and Outcomes of Arthroscopic Labral Reconstruction of the Hip: A Systematic Review. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2019.02.031

[142] Marked Decline in Revision Rate Over Time After Hip Arthroscopy for Femoroacetabular Impingement Syndrome. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/23259671251326112

[143] Borderline Dysplastic Hips Undergoing Hip Arthroscopy Achieve Equivalent Patient Reported Outcomes When Compared With Hips With Normal Acetabular Coverage: A Systematic Review and Meta-Analysis. Journal of the American Academy of Orthopaedic Surgeons. 2022. DOI: 10.5435/jaaos-d-22-00302

[144] Arthroscopic Versus Open Elbow Debridements Among ABOS Part II Candidates: A Decline in Arthroscopic Volume yet Fewer Complications After Arthroscopic Procedures. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261425647

[145] Hip Arthroscopy in Smokers: A Systematic Review of Patient-Reported Outcomes and Complications in 18,585 Cases. The American Journal of Sports Medicine. 2020. DOI: 10.1177/0363546520922854

[146] Concomitant Peri‐Acetabular Osteotomy and Arthroscopy Versus Isolated Arthroscopy With Capsular Plication for Borderline Dysplasia: Both Show Favorable Results. Arthroscopy. 2025. DOI: 10.1016/j.arthro.2025.02.032

[147] Editorial Commentary: The Warrior Athlete: An Illustrative Microcosm in the War Against Hip Femoroacetabular Impingement. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2018.07.005

[148] Segmental and Circumferential Acetabular Labral Reconstruction Have Comparable Outcomes in the Treatment of Irreparable or Unsalvageable Labral Pathology: A Systematic Review. Arthroscopy. 2021. DOI: 10.1016/j.arthro.2021.10.016

[149] Revision Hip Arthroscopy: A Systematic Review of Diagnoses, Operative Findings, and Outcomes. Arthroscopy. 2015. DOI: 10.1016/j.arthro.2014.12.027

[150] Low Rates of 5‐Year Secondary Surgery and Postoperative Complications After Primary Hip Arthroscopy in More Than 30,000 Patients. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2023.01.100

[151] Midterm Outcomes of Staged Bilateral Hip Arthroscopy for Femoroacetabular Impingement Syndrome Show Comparable Outcomes Between Time Interval More or Less Than 12 Months of Bilateral Procedures. Arthroscopy. 2026. DOI: 10.1002/arj.70069

[152] Harms Reporting Is Inadequate in Systematic Reviews Regarding Hip Arthroscopy. Arthroscopy, Sports Medicine, and Rehabilitation. 2023. DOI: 10.1016/j.asmr.2022.10.010

[153] Primary Repair of the Acetabular Labrum: Outcomes With 2 Years' Follow‐Up. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2014.02.007

[154] Complications and Reoperations During and After Hip Arthroscopy: A Systematic Review of 92 Studies and More Than 6,000 Patients. Arthroscopy. 2013. DOI: 10.1016/j.arthro.2012.11.003

[155] Assessing the Risk Factors for Surgical Site and Deep Wound Infections Following Hip Arthroscopy: A Nationwide Study of 75,577 Patients. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-00262

[156] Revision hip arthroscopic surgery: outcome at three years. Knee Surgery, Sports Traumatology, Arthroscopy. 2013. DOI: 10.1007/s00167-013-2373-7

[157] Elbow arthroscopy: state of the art. Journal of ISAKOS. 2017. DOI: 10.1136/jisakos-2016-000089

[158] Complication Rates for Hip Arthroscopy Are Underestimated: A Population‐Based Study. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.01.021

[159] Midterm Outcomes Following Repair of Capsulotomy Versus Nonrepair in Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement With Labral Repair. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2019.01.033

[160] Arthroscopic Management of Femoroacetabular Impingement: Minimum 2‐Year Follow‐up. Arthroscopy. 2011. DOI: 10.1016/j.arthro.2011.05.018

[161] Arthroscopy is here to stay. Journal of ISAKOS. 2017. DOI: 10.1136/jisakos-2017-000156

[162] Correction to: The likelihood of total knee arthroplasty following arthroscopic surgery for osteoarthritis: a systematic review. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05344-3